SANGAMON VALLEY PUBLIC WATER DISTRICT

Application for Water and Sewer Service

Application date:_____________

Date you intend to move in: _____________ Service Address: _____________________________________

Billing Address if different: _________________________________________________________________

Method of Occupancy: Own __________ Financed By: _________________________________________

* $50.00 Deposit Required *Rent __________From Whom: ________________________________________

*Contract Purchase ________From Whom: ________________________________

Previous Address: ___________________________________________________ How Long? _____________

Applicant: _____________________________________Email Address: ______________________________

Drivers License #: __________________________ SSN: _______________________________________

Home/Cell Phone #: ____________________________ Work Phone #: ________________________________

Name and Address of Current Employer:_________________________________________________________

Co-Applicant: __________________________________ Email Address: ______________________________

Drivers License #: ______________________________ SSN: _______________________________________

Home/Cell Phone #: ____________________________ Work Phone #: ________________________________

Name and Address of Current Employer:_________________________________________________________

Postcard bill by mail _______________or E-bill ________________________________________________

Application Signature: _______________________ Co-Applicant Signature: ________________________

Please complete back side of application-Thank you

------------------------------------------------------For Office Use Only-------------------------------------------------------

Deposit Paid: Date _____________________________ Received by: _________________________________

Revised – April 2019

 RACE AND ETHNICITY DATA COLLECTION

Title VI of the Civil Rights Act of 1964 requires “Race and Ethnic” data collection from beneficiaries of
federally assisted programs. Please note “Disclosure Clause” below:

“The following information is requested by the federal government in order to monitor compliance with
Federal laws prohibiting discrimination against applicants seeking to participate in the program. You are
not required to furnish this information, but encouraged to do so. This information will not be used in the
evaluation of your application or to discriminate against you in any way. However, if you choose not to
furnish it, Management is required to note race/ethnicity on the basis of visual observation or surname.”
If you do not wish to provide the information, please check the box below:
________ I do not wish to furnish this information.
Ethnicity: (Mark only one) Race: (Mark one or more)
________ Hispanic or Latino ________ American Indian/Alaskan Native
________ Not Hispanic or Latino ________ Asian
Gender: ________ Black or African American
________ Male _______ Female ________ Native Hawaiian or Other Pacific Islander
________ Information Provided by Management ________ White